Health, well-being, and burnout amongst Early Career Doctors in Nigeria

Background Early Career Doctors (ECDs) in Nigeria are faced with many individual and systemic problems, which consequently adversely affect their health, well-being, patient care and safety. Objective This study, the second phase of the Challenges of Residency Training and Early Career Doctors in Nigeria (CHARTING II) Study, sought to examine the risk factors and contributors to the health, well-being and burnout amongst Nigerian ECDs. Methods This was a study of health, well-being and burnout amongst Nigerian ECDs. Outcome variables included burnout, depression, and anxiety, which were respectively assessed using the Copenhagen Burnout Inventory (CBI) and Oldenburg Burnout Inventory (OLBI), Patient Health Questionnaire (PHQ-9) depression scale, and Generalized Anxiety Disorder (GAD-7) scale. The quantitative data obtained was analysed using the IBM SPSS, version 24. Associations between categorical outcome and independent variables were assessed using chi square, with level of significance set at < 0.05. Results The mean body mass index (BMI), durations of smoking and alcohol consumption of the ECDs were 25.64 ± 4.43 kg/m2 (overweight range), 5.33 ± 5.65 years and 8.44 ± 6.43 years respectively. Less than a third (157, 26.9%) of the ECDs exercised regularly. The most common disease conditions affecting the ECDs were musculoskeletal (65/470, 13.8%) and cardiovascular diseases (39/548, 7.1%). Almost a third (192, 30.6%) of the ECDs reported experiencing anxiety. Male and lower cadre ECDs were more likely than female and higher cadre ECDs to report anxiety, burnout and depression. Conclusion There is an urgent need to prioritize the health and well-being of Nigerian ECDs, so as to optimize patient care and improve Nigeria’s healthcare indices.


Introduction
Early Career Doctors (ECDs) are medical doctors in the cadre of pre-registration House Officers, Medical/Dental Officers below the rank of Principal Medical/Dental Officer (PMO/ PDO), and Resident Doctors (RDs) in Nigeria [1,2]. Being a heterogenous group of medical practitioners in this low-middle income country, ECDs are faced with a lot of demographic, workplace-related and psychosocial problems [3,4]. Amongst the psychosocial problems is burnout. Burnout rates of as high as 51.9% have been reported amongst Nigerian ECDs, and this was found to be significantly associated with long work hours [5,6]. Work hours of Nigerian doctors are currently not regulated, with RDs bearing the brunt of these long unregulated work hours [7]. A recent study reported that Nigerian RDs work an average of 123 hours/week [7]. Overwork proportionally correlates with high levels of stress, depression, poor personal relationships, reduced quality of life, and in the extreme, mortality amongst medical doctors [8][9][10]. Cumulative fatigue from long work hours, is therefore, not only detrimental to patients' safety, but deleterious to the overall well-being and health of physicians [11].
The physician's health and well-being must be prioritized if patient care is to be optimized. Physicians are better able to connect with, interact, serve, and care for patients when they (the physicians) are in good health [12]. Addressing the health and well-being of physicians does not only benefit the physicians, but also patients and the entire healthcare system [12]. It is in line with this reality that the Physician's Pledge has been revised, and the recent Charter on Physician Well-being made a renewed call for a partnership and commitment among medical professionals and healthcare organizations, to address the widespread problem of physician burnout, and promote a culture of well-being amongst physicians globally [12].
The long work hours, coupled with high burnout rates of Nigerian ECDs, is against the backdrop of a very low physician-to-patient ratio, limited slots/opportunities for training and career development, as well as poor renumeration [3,13]. A fallout of these, is the ongoing massive medical brain drain in the country, which if unchecked, has the potential of further worsening the already abysmal healthcare indices in the country [14,15]. There is therefore an urgent need to investigate and understand the full-scale of the problems faced by Nigerian ECDs, with a view to proffering relevant solutions, as well as address issues pertaining to their health and well-being. This need midwifed the Challenges of Residency Training and Early Career Doctors in Nigeria (CHARTING) Study, the largest, multi-centre, and multidisciplinary research on Nigerian ECDs, by the Research Collaborative Network (RCN), an ad hoc committee of NARD, established in 2018 [3]. The first phase of the Study (CHARTING I) examined the demographic, workplace and psychosocial issues affecting ECDs in Nigeria [3]. This second phase (CHARTING II) sought to examine other components of these issues, not explored in the first phase [4].

Study design
A cross sectional study of health, well-being and burnout amongst Nigerian ECDs. The study design have been previously described and published elsewhere [4].

Inclusion criteria
All ECDs in Nigeria, currently working in a NARD centre (a hospital in Nigeria, whose doctors belong to NARD), and who consent to participating in the study.

Exclusion criteria
All non-ECDs in Nigeria, and ECDs in Nigeria who are not working in a NARD centre.

Study site/location
This study was conducted among 76 public tertiary hospitals in Nigeria, from which NARD derives her membership.

Sampling method
A multi-stage sampling technique was used to recruit consenting participants in selected departments in the participating centres. The levels of sampling included: i. 31 centres were selected amongst the 76 NARD centres, across the six geopolitical zones of the country, viz: North West-5, North Central-7, North East-3, South South-5, South West-9, and South East-2; ii. 5-10 departments were selected in each of the selected 31 centres, in such a manner that accommodated the study sample size; iii. All willing and qualified participants in the selected departments of the 31 centres were recruited.
The participants were recruited from the selected departments in the participating centres. Participation was voluntary.

Sample size
A total of 629 ECDs were included in this report. This was based on the expected frequency of 50%, to accommodate the broad and non-availability in some instances, of the prevalence rate of some of the issues to be explored. A confidence interval of 5% was used, and the design effect was set at 4, based on the 31 clusters of the survey. The sample size was calculated using StatCalc of Epi Info 7 1 , produced by the Centres for Disease Control and Prevention.

Data collection tools/procedure
Similar to CHARTING I Study [1] the data collection tools included purpose-designed, structured questionnaires [3].

Data analysis
Quantitative data. The outcome variables included burnout, depression, and anxiety. Burnout was assessed using the Copenhagen Burnout Inventory (CBI) and Oldenburg Burnout Inventory (OLBI) [16]. The CBI consists of three sub-scales measuring personal burnout (6 items), work-related burnout (7 items), and client-related burnout (6 items) [11]. Twelve of the 19 items are rated along a five-point Likert scale according to responses of frequency from '100 (always)' to '0 (never/almost never)'. The remaining seven items rate the response according to an intensity which ranges from 'to a very low degree' to 'to a very high degree'. An item in the work-related burnout subscale requires inverse scoring and the item is: "do you have enough energy for family and friends during leisure time?" The level of burnout is classified according to the total scores obtained. A score of 0-50 implied 'no/low' burnout, 50-74, 'moderate' burnout, 75-99, 'high' burnout, and 100, 'severe' burnout [11].
Oldenburg Burnout Inventory measures burnout with two dimensions: exhaustion and disengagement [12]. The dimensions are evaluated using 16 items: 8 items measure exhaustion, and 8 items measure disengagement from work. Both dimensions are evaluated by four positively worded items and four negatively worded items. Items are scored by using a scale ranging from 1 to 4 (Strongly agree-Strongly disagree). Respondents were considered to be at high risk of burnout if they met the cut-offs of 2.1 and 2.25 for the exhaustion and disengagement subscales [12].
Depression was assessed using the Patient Health Questionnaire (PHQ) depression scale, which evaluates the severity of depression using 9 items (hence called PHQ-9), which consists of the actual nine criteria on which the diagnosis of DSM-IV depressive disorders is made [13]. Each of the 9 DSM-IV criteria is scored '0' (not at all) to '3' (nearly every day). Question 9 is a single screening question on suicide risk. A respondent who answers 'yes' to question 9 needs further assessment for suicide risk by an individual who is competent to assess this risk. Total scores of 5, 10, 15, 20 represent cut-offs for mild, moderate, moderately severe, and severe depression [13].
Anxiety was assessed using a 7-item Generalized Anxiety Disorder scale (GAD-7) [14]. Each of the 7 items is scored '0' (not at all), '1' (several days), '2' (more than half the days), and '3' (nearly every day), giving a total score of 21. Scores of 5, 10 and 15 are taken as the cut-off points for mild, moderate and severe anxiety respectively [14].
This data obtained was analysed using the IBM SPSS, version 24. Categorical variables were expressed as frequency and percentage while continuous variables were expressed as mean and standard deviation or median and interquartile range (IQR) as appropriate. Associations between categorical outcome and independent variables were assessed using chi-square. Independent samples t-test and Mann Whitney U test were used to compare the variables between two categories while Kruskal Wallis test and ANOVA was used to analyse continuous variables with more than three groups. P-value < 0.05 was significant.

Ethical considerations
This study, is part of the second phase of the Challenges of Residency Training and Early Career Doctors in Nigeria (CHARTING II) Study, and approval was obtained from the National Ethics Review Committee of the Nigerian Federal Ministry of Health with approval number: NHREC/01/01/2007-26/06/2019 [4]. Informed consents were also obtained from all the study participants, after diligently explaining the study objectives and rationale to them. The questionnaires were anonymous, and the database was passworded, accessible to only approved members of the research team.

Sociodemographic characteristics of Nigerian ECDs
The mean age of the ECDs in our study was 32.81 ± 5.37 years. Most of them were males (413, 65.7%), married (346, 55.0%), and Registrars (280, 44.5%), with mean years of medical practice of 6.55 ± 4.22 years. These sociodemographic characteristics are shown in Table 1.

Lifestyles and current health status of Nigerian ECDs
The mean body mass index (BMI) of the ECDs was 25.64 ± 4.43 kg/m 2 (overweight range). Female ECDs were significantly more likely to be overweight compared with male ECDs (26.24 ± 5.27 kg/m 2 vs. 25.34 ± 3.96 kg/m 2 ; p = 0.033). The ECDs reported mean durations of smoking and alcohol consumption of 5.33 ± 5.65 years and 8.44 ± 6.43 years respectively. Less than a third (157, 26.9%) of them exercised regularly.
The majority of ECDs with CVDs were diagnosed within their years of medical practice (31/ 39, 79.5%).

Discussion
This a large study, a few of such among ECDs in Sub Saharan Africa to evaluate their overall health. Dietary habits such as eating lunch out of home, and snacking between meals, chronic stress with little sleep, coupled with sedentary and urban lifestyles, make doctors prone to overweight and obesity [17,18]. Female gender and physical inactivity were risk factors for the prevalent overweight status of the ECDs in our study. Similar to the findings in other studies, overweight amongst female doctors may not be unconnected with their relatively more

PLOS ONE
Health, well-being and burnout amongst ECDs in Nigeria sedentary lifestyle, hormonal and physiological factors such as pregnancy, and lactation [17][18][19]. Our study also found that higher cadre ECDs were significantly more likely to be overweight compared to lower cadre ECDs. Aside from the fact that lower cadre ECDs were more likely than their more senior colleagues to engage in regular physical exercises, as found in this study, this finding may not be unconnected with the older age, higher incomes, and higher likelihood of being married of higher cadre ECDs, as increasing age, marital status, and higher socioeconomic status have been documented to be associated with an increased likelihood of being overweight and obesity [19,20]. More so, compared with higher cadre ECDs, lower cadre ECDs work longer hours (as seen in this study), and are therefore more physically active, thus reducing the risk of being overweight. The high prevalence of overweight amongst ECDs in our study has negative implications on their clinical practices and personal health. Overweight doctors are less likely than their normal weight counterparts to counsel/advise overweight or obese patients on weight loss strategies/healthy weight management practices [18,21]. Obesity also increases the risks of CVDs, diabetes mellitus (DM), stroke, osteoarthritis, sleep apnoea, gynaecological problems including amenorrhoea, menorrhagia, and infertility, as well as various malignancies [17,20]. This possibly explains the frequency of cardiovascular and musculoskeletal diseases, which were the most common disease conditions affecting ECDs in our study. The higher incidence of CVDs, respiratory diseases, and cancers amongst male and lower cadre ECDs compared to females and higher cadre ECDs in our study, may not be unconnected with the higher alcohol consumption and tobacco smoking of the former compared to the latter. Smokers have a higher risk of mortality from hypertensive heart disease, respiratory diseases, and cancers, amongst others [22]. The cardiovascular health benefits of reduction in alcohol consumption, even for light to moderate drinkers, is also documented in the literature [23]. In addition, it has been demonstrated that in younger age groups, females have a lower risk of CVDs [24]. This may also possibly explain the higher incidence of CVDs amongst the male ECDs in our study.
The male ECDs in our study reported longer routine work and on-calls hours. Given that 65% of the respondents in our study were RDs, a preponderance of males in the surgical specialties, which are characterised by longer work hours, with little sleep, compared to the nonsurgical specialties [6], may explain the longer routine work and on-call hours reported by the male ECDs. The higher physical demand, including long theatre hours of surgical specialties make these specialties less attractive to females [25]. There is a significant association between burnout and long work hours [4,5]. This possibly explains why male and lower cadre ECDs, who worked longer hours compared to female and higher cadre ECDs, reported higher rates of burnout. Feelings of being overwhelmed, low self-esteem, and desire to quit medical practice/residency, as reported more by ECDs who worked longer hours in our study, are the result of burnout [6,26,27]. A positive correlation between burnout, and anxiety and depression has also been reported [28]. Burnout is a precursor to depression [12]. Our study corroborated these findings, as ECDs who had higher levels of burnout, also reported more anxiety and depression. Aside from anxiety and depression, physician burnout is associated with suicidal ideation, substance abuse, poor interpersonal and marital relationships, increased medical errors, and poor quality of patient care, amongst others [28]. Our study confirmed these findings, as male and lower cadre ECDs, who reported longer work hours, burnout, anxiety and depression, also alluded to having more suicidal ideation, alcohol consumption, tobacco smoking, and bad work life balance, compared to female and higher cadre ECDs. The long work hours of Nigerian doctors, with the consequent high rates of burnout, anxiety, depression, and other adverse sequelae, may not be unconnected with massive medical brain drain currently bedevilling the country, which is the result of poor remuneration and working conditions, limited slots/opportunities for training, research, and career development, amongst others [6,28]. A consequence is the country's current abysmal physician-topatient ratio of 4:10,000 (a far cry from the WHO's recommendation of 1:600), which has the potential of further worsening her already poor morbidity and mortality statistics [6,28].
A limitation of this study is the possibility of recall bias, as the data generated were based on self-reported information by the study participants. Another limitation is the inability to determine a true temporal link between cause and effect, as both were examined simultaneously, given the study design. These limitations notwithstanding, this study is the first in Nigeria to investigate key issues relating to the health, well-being, and burnout amongst Nigerian ECDs on a large scale-a nationally representative one. A probability sampling technique was adopted in this study, which gave all eligible participants an equal chance of participating in the study; hence, the possibility of selection bias was reduced to the barest minimum or absent. The study provides important data upon which relevant stakeholders can plan policies and interventions to address the health-related and psychosocial problems affecting ECDs in Nigeria.

Conclusion
Our study clearly highlights the need to prioritize the health and well-being of Nigerian ECDs. It is beneficial for ECDs to adopt healthy lifestyles including regular exercises, cessation of smoking, and reduction of alcohol consumption. Hospitals should have facilities for physical exercises. There is an urgent need to address the systemic and individual challenges of Nigerian ECDs, with a view to providing solutions, and mitigating the negative impacts of these problems on the health and well-being of the ECDs, as well as on patient care and safety. Work hours of Nigerian doctors should be capped, and their working conditions, improved. Interventions that address burnout before anxiety and depression set in, would be beneficial.